B
Financial Resources of States for HIV/AIDS Reporting

Several of the factors determining system accuracy, such as the ability to follow up on a backlog of cases, depend on the capacity to conduct surveillance. As one indicator of capacity, the Committee examined federal and state funding for HIV/AIDS case reporting. The Committee heard testimony from a small number of states, from the Centers for Disease Control and Prevention (CDC) staff, and from select Eligible Metropolitan Areas (EMAs) regarding surveillance capacity and funding. The Committee also reviewed information provided by state AIDS programs and from the CDC regarding state and federal contributions to HIV/AIDS surveillance for fiscal years 1999–2002.

With the exception of very large county or city health departments, state surveillance programs provide the HIV/AIDS surveillance data for Ryan White CARE Act (RWCA) planning and evaluation. While HIV reporting has been implemented in all states and cities, except Georgia and Philadelphia (as of October 2003), most states did not see a concurrent increase in financial resources to assist with the implementation of HIV reporting. Although the RWCA Amendments of 2000 authorized limited additional funds to assist states with the implementation of HIV reporting systems (Ryan White CARE Act. Sec. 300ff-13), that funding has yet to be appropriated. Even though HIV and AIDS data are perceived to be readily available for RWCA purposes at no additional cost, states must often provide specialized reports for RWCA planning that include different or more-detailed data than are provided in standard epidemiologic reports.1 Such efforts can be costly.

1  

Subcommittee site visit to the CDC, April 4, 2002.



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Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act B Financial Resources of States for HIV/AIDS Reporting Several of the factors determining system accuracy, such as the ability to follow up on a backlog of cases, depend on the capacity to conduct surveillance. As one indicator of capacity, the Committee examined federal and state funding for HIV/AIDS case reporting. The Committee heard testimony from a small number of states, from the Centers for Disease Control and Prevention (CDC) staff, and from select Eligible Metropolitan Areas (EMAs) regarding surveillance capacity and funding. The Committee also reviewed information provided by state AIDS programs and from the CDC regarding state and federal contributions to HIV/AIDS surveillance for fiscal years 1999–2002. With the exception of very large county or city health departments, state surveillance programs provide the HIV/AIDS surveillance data for Ryan White CARE Act (RWCA) planning and evaluation. While HIV reporting has been implemented in all states and cities, except Georgia and Philadelphia (as of October 2003), most states did not see a concurrent increase in financial resources to assist with the implementation of HIV reporting. Although the RWCA Amendments of 2000 authorized limited additional funds to assist states with the implementation of HIV reporting systems (Ryan White CARE Act. Sec. 300ff-13), that funding has yet to be appropriated. Even though HIV and AIDS data are perceived to be readily available for RWCA purposes at no additional cost, states must often provide specialized reports for RWCA planning that include different or more-detailed data than are provided in standard epidemiologic reports.1 Such efforts can be costly. 1   Subcommittee site visit to the CDC, April 4, 2002.

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Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act When considering the question of surveillance capacity, there are at least two levels of system cost: one associated with the implementation of HIV reporting, and the other associated with RWCA planning efforts at state and local levels. Cost issues are relevant to the question of capacity, particularly given the pervasive fiscal austerity of states and localities. DATA EXAMINED Financial resources clearly affect reporting capacity. In the absence of models to estimate surveillance costs, the Committee attempted to understand more about surveillance capacity by studying the distribution of federal and state funding for surveillance programs. The Committee reviewed two sources of funding for state HIV/AIDS surveillance programs for the years 1999 through 2002: (1) self-reported state general revenue contributions for HIV and AIDS surveillance, and (2) federal core surveillance funding to states through cooperative agreements with the CDC.2 The National Alliance of State and Territorial AIDS Directors (NASTAD) administered a request for information to state AIDS directors regarding states’ general revenue contributions to their HIV/AIDS surveillance programs during fiscal years 1999–2002. Forty-one states responded to that request for information.3 States were also asked to identify expected changes in general revenue (remain constant, decrease, increase). The CDC provided data to the Committee on federal funding to states for core surveillance and for other surveillance activities for corresponding fiscal years 1999 through 2002 (CDC, 2003). The Committee reviewed data for 1999 through 2002 for three reasons: (1) approximately one-third of states implemented HIV reporting during this time period (see Table 3-1 in chapter 3), (2) state fiscal austerity was emerging during this time period, and (3) these data were readily available from most states. 2   CDC provides “core funding” to states for their HIV/AIDS reporting systems. CDC provides additional funds to states, based on a competitive grant application process, for supplemental surveillance activities. 3   States were asked not to include state general revenue contributions to the six cities/counties in their jurisdiction that receive direct funding from CDC for HIV/AIDS reporting (Chicago, Houston, New York, Los Angeles, Philadelphia, and San Francisco). A separate request for information was made to those areas. States were also asked to exclude in-kind contributions (e.g., staff on loan from another division) and funding for general communicable disease or sexually transmitted disease surveillance.

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Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act RESULTS The Committee examined data provided by the CDC and NASTAD on federal and state contributions for HIV surveillance. The Committee converted the total spending to spending per capita, using data from the 2000 Census (U.S. Census Bureau, 2000). During 1999–2002, the majority of funds for AIDS and HIV surveillance programs came from the federal government, and in 32 states, funding was entirely from the federal government. Average federal and state funding was flat from 1999–2002. Relative state contributions were flat during the period with less than 10 percent of the total average $0.09–$0.10 spent per capita. Moreover, 33 of the 41 states that responded reported $0 of state general revenue funding for HIV/AIDS surveillance programs for fiscal years 1999, 2000, and 2002. Thirty-two states reported $0 state contributions in fiscal year 2001. State-by-state comparisons of federal and state HIV/AIDS surveillance funding for 1999–2002 in dollar terms is found in Table B-1. State contributions to HIV/AIDS surveillance funding are only provided for the 41 states that responded to NASTAD’s request for information. Federal contributions are provided for all 50 states and the District of Columbia. The funding picture for state HIV/AIDS surveillance programs did not change appreciably during FY1999–2002 for the 41 states that responded to the request for information.4 Table B-2 shows state general revenue contributions for HIV/AIDS surveillance as a percentage of total surveillance budgets. The aggregate reliance on federal resources for HIV/AIDS surveillance does not change greatly from year to year. Table B-3 presents data from the 11 states that implemented HIV reporting during the analysis period. These data show that for the majority of these states, there was little change in the amount of state or federal funding for surveillance during the period when they were implementing HIV reporting. Only California substantially increased funding in the years just prior to implementation of HIV reporting. Pennsylvania began general revenue contributions prior to implementing HIV reporting, but Kansas discontinued general revenue contributions the year following implementation of HIV reporting. Federal funding increased for Vermont, Hawaii, Alaska, and Kansas during this period, but was essentially flat for other states. 4   Financial data were adjusted for inflation using the All Items Consumer Price Index. U.S. City average, nonseasonally adjusted, All Urban Consumers. (U.S. Department of Labor, Bureau of Labor Statistics). [Online] http://data.bls.gov.SeriesID:CUUS0000SA0.

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Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act TABLE B-1 State and Federal Contributions for HIV/AIDS Surveillance for FY1999–2002, in Dollars (N=51)   FY1999 FY2000 State State General Revenue (in $) Federal Revenue (in $) State General Revenue (in $) Federal Revenue (in $) Alabama Not Available* 572,603 Not Available 786,712 Alaska 0 115,000 0 115,000 Arizona 125,000 340,573 125,000 398,133 Arkansas 0 238,727 0 207,653 Californiaa 5,116,200 3,914,875 7,746,000 4,058,017 Colorado 0 537,822 0 467,772 Connecticut Not Available 346,444 Not Available 298,319 Delaware 0 112,664 0 113,005 District of Columbia Not Available 388,336 Not Available 485,865 Florida 634,227 1,806,242 634,227 1,760,761 Georgia 0 196,816 0 297,909 Hawaii 0 31,505 0 135,989 Idaho 0 75,000 0 75,000 Illinois Not Available 1,010,508b Not Available 1,409,531b Indiana 0 274,633 0 280,708 Iowa 0 29,476 0 129,151 Kansas 42,900 90,200 42,900 127,301 Kentucky 0 109,852 0 117,000 Louisiana 7,500 772,966 7,500 774,042 Maine 0 112,947 0 72,319 Maryland Not Available 956,359 Not Available 956,359 Massachusetts 0 226,901 0 483,925 Michigan 0 851,426 0 881,745 Minnesota 0 189,568 0 232,345 Mississippi 0 243,071 0 220,000 Missouri 0 550,203 0 577,455 Montana 0 68,105 0 67,124 Nebraska 0 83,635 0 120,000 Nevada Not Available 310,600 Not Available 327,494 New Hampshire Not Available 83,200 Not Available 77,985 New Jersey 616,000 2,202,177 553,000 2,089,025 New Mexico Not Available 163,320 Not Available 213,479 New York 1,607,028 4,525,303c 1,809,183 4,394,123c North Carolina 0 406,125 0 1,292d North Dakota 0 59,675 0 59,251 Ohio 0 176,228 0 399,052 Oklahoma 0 286,509 0 286,509 Oregon Not Available 330,108 Not Available 320,108 Pennsylvania 0 1,079,110e 0 1,092,184e Rhode Island Not Available 213,218 Not Available 214,304 South Carolina 0 446,217 0 486,314

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Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act FY2001 FY2002 State General Revenue (in $) Federal Revenue (in $) State General Revenue (in $) Federal Revenue (in $) Not Available 551,606 Not Available 557,276 0 120,750 0 120,750 125,000 423,863 125,000 380,226 0 218,036 0 218,036 7,746,000 3,927,473 7,746,000 4,042,160 0 522,250 0 318,972 Not Available 433,988 Not Available 454,338 0 126,864 0 126,904 Not Available 487,435 Not Available 510,158 634,227 1,896,204 634,227 183,146 0 69,973 0 384,666 0 173,417 0 173,418 0 78,750 0 64,184 Not Available 750,838b Not Available 988,642b 0 362,653 0 325,508 0 169,198 0 143,412 42,900 135,344 0 130,144 0 122,850 0 122,850 7,500 812,010 7,500 322,866 0 103,530 0 106,688 Not Available 988,653 Not Available 874,028 0 488,190 0 409,864 0 925,832 0 924,110 0 144,096 0 247,094 0 132,424 0 132,720 0 601,078 0 601,078 0 63,100 0 67,772 0 126,000 0 126,000 Not Available 343,869 Not Available 343,870 Not Available 87,681 Not Available 76,838 692,000 2,260,092 400,000 2,224,150 Not Available 179,071 Not Available 153,312 1,726,081 4,097,758c 1,590,230 4,484,826c 0 228,949 0 374,534 0 61,067 0 62,214 0 481,189 0 516,746 0 300,834 0 300,834 Not Available 326,113 Not Available 336,114 100,000 1,128,759e 100,000 966,010e Not Available 226,169 Not Available 226,170 0 501,745 0 371,358

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Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act   FY1999 FY2000 State State General Revenue (in $) Federal Revenue (in $) State General Revenue (in $) Federal Revenue (in $) South Dakota 0 52,048 0 54,404 Tennessee 0 526,858 0 505,200 Texas 263,006 1,627,176f 263,006 1,401,897f Utah 0 115,481 0 141,092 Vermont 0 64,294 0 75,056 Virginia 0 339,806 0 423,268 Washington 0 748,702 0 760,952 West Virginia 0 182,351 0 204,419 Wisconsin 0 342,445 0 342,445 Wyoming 0 52,690 0 52,689 aIncludes funding for Los Angeles and San Francisco. bIncludes funding for Chicago. cIncludes funding for New York City. d$1,292 was allocated to North Carolina in 2000 due to unexpended and carryover funding from the previous year. eIncludes funding for Philadelphia. fIncludes funding for Houston. *Not available means there was no response to NASTAD’s request for information. NOTE: Data from states is self-reported and has not been independently verified. SOURCE: NASTAD, 2003. TABLE B-2 State Funding for HIV/AIDS Surveillance as a Percent of Total State HIV/AIDS Surveillance Budget, FY1999–2002 (N = 41) Fiscal Year Mean (%) 1999 4.48 2000 4.36 2001 4.65 2002 3.51

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Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act FY2001 FY2002 State General Revenue (in $) Federal Revenue (in $) State General Revenue (in $) Federal Revenue (in $) 0 47,024 0 44,454 0 581,102 0 616,100 268,872 1,308,762f 268,872 1,086,330f 0 168,719 0 179,268 0 128,832 0 82,526 0 444,332 0 393,084 0 802,181 0 770,510 0 199,627 0 225,750 0 383,851 0 341,914 0 51,555 0 57,954 TABLE B-3 State and Core Federal Funding for Surveillance by States Implementing HIV Surveillance per 1,000 Adult Population, FY1999–2002, by State (N = 11)   State Funding (in $) Federal Funding (in $) State 1999 2000 2001 2002 1999 2000 2001 2002 Alaska 0* 0 0 0 20* 20 190 190 California 150 230 230 230* 120 120 120 120* Delaware 0 0 0* 0 160 140 160* 160 Hawaii 0 0 0* 0 30 110 140* 140 Kansas 20 20 20 0 30* 50 50 50 Kentucky 0 0* 0 0 30 30* 30 10 Maine 0* 0 0 0 90* 60 80 80 Montana 0 0* 0 0 80 70* 70 80 New York 80 100* 90 80 80 80* 90 80 Pennsylvania 0 0 10 10* 40 40 40 40* Vermont 0 0* 0 0 110 120* 210 140 *Year of HIV surveillance implementation

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Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act As one of several potential indicators of capacity, these data imply that more financial resources might be required to accommodate the current and additional information needs or demands of the HIV/AIDS surveillance programs vis-à-vis use of information for RWCA planning, allocation, or evaluation. States are facing significant financial crises, and while several states are newly implementing HIV reporting, most programs do not anticipate additional state general revenue contributions. According to the 41 states that responded to the NASTAD request for information, 65 percent (27) reported that they expect their state’s contributions for HIV/AIDS surveillance to remain constant; 7.3 percent (3) reported that they expect a decrease; while 2.4 percent (1) reported they expect an increase. State dependence upon federal funding for HIV surveillance activity, and for the provision of HIV/AIDS data for RWCA planning, evaluation, and allocation is apparent. The use of financial data to understand capacity has limitations. For example, some resources used for other surveillance may partially support HIV/AIDS surveillance. Furthermore, the Committee did not have the ability to calculate the incremental costs of implementing specific HIV surveillance and reporting activities. Nevertheless, it appears that states are being required to engage in additional surveillance and reporting activities without a commensurate increase in state or federal resources. Additional assessments of the incremental costs of such activities would be helpful in determining overall funding needed to support HIV/AIDS surveillance activities. REFERENCES CDC (Centers for Disease Control and Prevention). 2003. FY02 Surveillance by State Final. (Email communication, Patricia Sweeney, CDC, May 2, 2003). NASTAD. 2003. Request for Information: State/Local Funding for HIV/AIDS Surveillance. U.S. Census Bureau. 2000. Population, Housing Units, Area and Density (geographies ranked by total population). [Online]. Available: http://factfinder.census.gov/ [accessed June 25, 2003]. U.S. Department of Labor. Bureau of Labor Statistics. [Online]. Available: http://data.bls.gov. Series ID: CUUS0000SA0.